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Avoidant Restrictive Food Intake Disorder

How is Avoidant Restrictive Food Intake Disorder (ARFIDO) different from all those eating disorders people have come to know? And did we really need another eating disorder diagnosis?

Proposed for the new DSM-V and looking like a for-sure new recognized eating disorder is ARFIDO. ARFIDO has some differences from past eating disorders. Given the many possible bad relationships with food people could become involved with, my take is yes this one is different from either Anorexia Nervosa or Bulimia and it has been needed for some time.

The way we have been looking at eating disorders has had some flaws for a while now. McFarland et al in 2008 wrote an interesting article on eating disorder relapse. The topic of relapse and relapse prevention has been an important part of substance abuse treatment for a long time. Recently we have been looking at the issue of relapse related to mental health issues.

In his article McFarland reported that they ended up including all the people with an eating disorder in the relapse study because people with an eating disorder move between disorders often enough to prevent saying someone has one and only one eating disorder.

We also are told in this article that the majority of people in treatment for an eating disorder, up to 60% of those treated in outpatient, did not meet the criteria for one of the official diagnosis and ended up in the left over category Eating Disorder Not otherwise specified (NOS).

Creating a new disorder (ARFIDO) is supposed to reduce the number of people who were ending up in that vague NOS land.

People with ARFIDO are different from those with anorexia nervosa or bulimia in several important ways. (I have taken liberties with the new DSM-V criteria here for sake of explanation.)

1. They do not have the characteristic distorted body image.

Ask a person with anorexia what they think about their current weight and they will tell you they are fat. Show them their reflection in the mirror, bones sticking out and all and they will still say they look fat. They see themselves at fat and no facts, not even the scale and the standard weight charts, will change that perception.

People with ARFIDO do not think they are fat.

They know they are thin, abnormally thin, but they like it that way. They become proud of their ability to stay thinner than most. They will keep up the dieting even when they know they are developing a health problem or nutritional deficiency because they like being one of the thin ones.

2. They don’t especially like food, food is the enemy.

People with ARFIDO will avoid many or all foods. They may need to resort to nutritional supplements to keep their weight above the critical go-to-hospital point.

3. They avoid putting on weight as they grow or in adulthood lose excessive amounts of weight.

They will continue avoiding food even when they know they are making themselves sick by their intentional starvation. Like Pieter Pan they do not want to grow up or get larger.

4. This is not the result of starvation or lack of resources. People with ARFIDO do this on purpose. The will harm their health to look thin while living in a home with a full refrigerator.

5. Because they are so good at avoiding eating, people with ARFIDO do not have the need for the extreme measures we see in anorexia Nervosa or Bulimia.

That is my understanding of this new diagnostic category at the current point in time. The new DSM will be out early next year and we can all get the full details then.

The update I read at the APA site was May 14-2012. They also note that when this is all done they expect there to be three sub types of ARFIDO, A People who do not eat and are not interested in eating B People who will only eat food with certain sensory characteristics, C People who won’t eat because of an aversive experience.

Other posts about eating disorders and the new DSM-V proposals will be found at:

So do you think that this creation of ARFIDO will improve recognition of poorly recognized eating disorders? Do you believe you or someone you know has had an episode of Avoidant Restrictive Food Intake Disorder? If you recovering from or have you had a relapse to Avoidant Restrictive Food Intake Disorder would you care to leave a comment?

For more about David Joel Miller and my work in the areas of mental health, substance abuse and Co-occurring disorders see the about the author page. For information about my other writing work beyond this blog there is also a Facebook authors page, in its infancy, up under David Joel Miller. Posts to the “books, trainings and classes” category will tell you about those activities. If you are in the Fresno California area, information about my private practice is at counselorfresno.com. Thanks to all who read this blog.

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I have this disorder. I avoid foods for sensory issues. I am not thin. I am not avoiding food to be thin. I eat only a few foods and will gag if I attempt to eat many foods. I love to eat, I just hate most foods. Do a search for adult picky eaters. I think you are only exploring one sub type of the new dsm5 criteria.

my grandson who is 4yrs old i believe has this disorder!!! he never ate baby food,has never ate bread he eats pop corn dorito chips,pizza crust no cheese sauce or pepperoni,bacon,white rice,and spaghetti noodles it has to have meat sauce on it but he will not eat the meat,french fries,the breading off of chicken nuggets!!! That is it has never had anything else and its very aggravating!!!!!

While it is possible he is avoiding food or restricting his food intake, it is also possible he is an extremely picky eater. Many but not all children grow into a wider range of foods as they get older and see other children eating things. I would check with his primary doctor and see that he is developing normally. It is worth continuing to try to increase the range of foods he eats. Turning eating and meals into battlegrounds are not productive as this can encourage the development of some eating disorders. We think that many eating disorders are not about food but about the ability to control things. Keep trying and see what happens.

It is my understanding, based on studies conducted by the Dept of Pediatrics, University of Rochester Medical Center, and the Dept of Psychiatry, University of Pittsburgh School of Medicine with Duke University Medical Center, that ARFID is not at all about being “proud of their ability to stay thinner than most”, dieting, or not wanting to grow up, as you have claimed.

Timothy Walsh, M.D., chair of the Feeding and Eating Disorders Work Group for DSM-5 defines Avoidant / Restrictive Food Intake Disorder as an “eating or feeding disturbance that includes, but is not limited to, apparent lack of interest in eating, avoidance based on the sensory characteristics of food, or concern about aversive consequences of eating that results in persistent failure to meet appropriate nutritional and/or energy needs.”

It is very different from the typical toddler pickiness, which is a normal part of child development. What has caught the attention of the psychiatric community about ARFID is the fear of food and the anxiety caused by the mere thought of eating.

Perhaps you could cite the sources you used to present the information you have posted?

Thanks for adding that comment to the discussion. My primary sources were the original proposal for revising the DSM which at the time I wrote the blog post was up at the APA site but has since been removed. We will have to wait for the book. My other source was a piece by McFarland Et al 2008 which was primarily about how we would know if someone with an eating disorder got better or if they relapsed.
Note also that my post concludes by saying that the proposed new disorder will have three very different sub types. My first five points were not meant to define ARFID but to paraphrase comments in the proposed criteria set that would help differentiate it from other current and proposed new eating disorders. No one of those points or even all of them may apply to any person with ARFID as I currently understand it but they do point to the problem that the list of eating disorders as we have had it since the DSM-IV does not cover all the possible eating disorder problems. Clearly the era when eating disorders were only defined by overly skinny people has ended. Being very heavy is no longer defined as being “healthy.” We still have a long way to go to understand all the problematic relationships people may have with food, eating or weight.
A larger questions remains. Why are the insurance companies asking me if I am prepared to give up the DSM and switch to using the ICD-10 to code diagnosis? Will the new ICD agree with the new DSM or will your eating disorder change if you move across international borders?

Is this a common issue with ICD codes? Does an individual’s schizophrenia or autism change from nation to nation? But ICD codes are another matter for another discussion.

As for this topic, the DSM is evolving to recognize different kinds of disordered eating, however, the liberties you have taken with the new DSM-V criteria “for the sake of explanation” do not accurately reflect the proposed criteria for ARFID or the nature of this disorder.

It is already extremely difficult to find a healthcare professional who will acknowledge, let alone treat this kind of disordered eating. Those affected are frequently ostracized and commonly dismissed by the medical community, likely because there is no diagnosis currently available. It is truly disheartening to know that this eating disorder is on the cusp of official medical recognition, yet physicians and therapists still feel it is nothing more than willful stubbornness, as it is implied by this post.
* * *
Because it is no longer on the dsm5.org site, here is the May 14, 2012 proposed criteria for ARFID:

Avoidant/Restrictive Food Intake Disorder

A. Eating or feeding disturbance including but not limited to
apparent lack of interest in eating or food;
avoidance based on the sensory characteristics of food or concern about aversive consequences of eating

as manifested by persistent failure to meet appropriate nutritional and/or energy needs associated with one or more of the following:

B. There is no evidence that lack of available food or an associated culturally sanctioned practice is sufficient to account for the disorder.

C. The eating disturbance does not occur exclusively during the course of Anorexia Nervosa or Bulimia Nervosa, and there is no evidence of a disturbance in the way in which one’s body weight or shape is experienced.

D. The eating disturbance is not better accounted for by a concurrent medical condition or another mental disorder. When occurring in the context of another condition or disorder, the severity of the eating disturbance exceeds that routinely associated with the condition or disorder and warrants additional clinical attention.
* * *

As you indicated this was one of your sources for this article. How did you conclude from this information that people with ARFID intentionally starve themselves? “The [sic] will harm their health to look thin while living in a home with a full refrigerator.” “Like Pieter Pan they do not want to grow up or get larger.”

Thanks for providing that information. I think you are misinterpreting what I was trying to say. The comments you refer to were not related to Avoidant Restrictive Food Intake Disorder but to criteria C. The way most of us were trained was to look first for anorexia in which there is often distorted body image and a failure to eat even when food is available. In the past most people diagnosed with an eating disorder were female and the first onset was at the onset of puberty. Teen girls who got teased about their changing body would diet to avoid developing sexual characteristics an almost peter Pan Type behavior. Secondly we have begun to look for episodes of binge eating, a phenomena similar to impulse control issues seen in addiction. In Bulimia there is compensatory behavior. Later we began to look for impulsive eating without compensation, sometimes called emotional eating. Binge eating has now made its way into our diagnostic categories. What will change radically in the near future is changing the category from “eating disorders” to Disorders of both eating and feeding. In the past all feeding disorders were in the section on “Disorders first diagnosed in childhood, infancy and adolescence.” Things like Pica and rumination disorders. This is a major change in our way of thinking about food related disorders.
We made this change some time ago in discussions about ADD (which is no longer ad accepted label) and ADHD. This used to be largely diagnosed in children we now believe that it also occurs and is missed in adults. My thinking is that most people with Avoidant Restrictive Food Intake Disorder and any of the other new eating and feeding disorders will probably need to be treated by specialized providers. In practice I see thousands of people with adjustment disorder as a result of a divorce or job loss and thousands more people with substance abuse problems for every one person that has an eating and feeding disorders.

I’m left feeling empty and confused by this article. Mr. Miller, have you ever actually met anyone with ARFID? And when did the “O” get added on the acronym, isn’t “disorder” one word? I am a 31 year old law student and have suffered from this my whole life. I have been a heavy advocate of “picky eaters” for a long time and continuously find myself frustrated when is condition is unreasonably misunderstood. There are many children and adults who would love to help articulate what is going on with us as we best understand it. All you need to do is ask.
This new disorder has NOTHING to do with weight. Nothing. It’s perhaps a byproduct at best but if there is a heavy concentration of research to looking comparing body image to those with sensory issues regarding food, then precious time and resources are being wasted. Unfortunate.

Thanks for adding to the discussion. My point in writing about the PROPOSED new disorders was to highlight how our understanding of mental illness was changing. Since my post the proposed text for the DSM-5 was taken down. For now we will have to wait to purchase the new book be sure of the results. The proposal as I understood it was to remove the distinction between disorders first diagnosed in childhood and adult disorders. So that regardless of when the issue first arises it is understood as the same disorder. Up till now there has been no official recognition that this (ARFID) was a disorder, so no at this point, no one has yet diagnosed this or any of the new disorders as they were not included in the DSM-IV. Criteria for proposed new disorders for study are used to screen patients in field trials. Some of these proposed criteria sets are eventually adopted.
Until now all these possible new disorders were placed as Eating Disorders Not Otherwise Specified (NOS.) The convention has been that the first time you use an expression (ARFID or ARFIDO) it is spelled out, after that initial use it is placed in the parenthesis. I chose to add the “O” in this piece to clarify that I was referring to a “disorder” not a disease. Try looking in either DSM for TSD or MST which are commonly used in the research papers to mean “Trauma Spectrum Disorder” or “Military Sexual Trauma.”
If an official abbreviation is created then by all means I will use it. There was a disagreement between those who worked on the DSM-IV and the DSM-V work groups. This new disorder and other new eating disorders will all appear in the same eating disorder section.
While the new disorder may have nothing to do with weight, people who receive this disorder in the future will probably routinely be screened for weight as weight loss and inability to maintain normal weight are diagnostic criteria for other disorders included in the eating disorder section.
I am pleased for you that the disorder you have may finally be recognized in May of 2013. Having it as an official diagnosis will help speed research and possible treatment. I can sense from your comment that this issues has caused you a lot of problems.
Many other proposed disorders did not receive recognition in the new DSM-V. One reason I am suspicious is that no person ever seems to fit neatly into a diagnostic category. Each person is a unique individual. We need to be sure that unique disorders get recognized and treated while avoiding creating 6 billion spate disorders. I encourage you to continue to educate the public and professionals about this disorder.

Hi – My name is Sian and have suffered from anorexia for over a decade now. Sometimes severe, sometimes not so – I can also proudly say that i am the mother of an 18 month old boy Noah whom is too perfect for his mothers sins. Can I say one thing – something insignificant and probably dull – but i read this article, as well as many others on the topic of anorexia, and this always “niggles” me.
Most literature on anorexia claims that sufferers always feel too fat and cant see what others can see in them. They don’t cringe at the bones, instead seeing phantom fat and imperfections.

This is not the case, in my experience. I have always known, full well, how thin I am. i can see it as clear as day and it’s my fuel, my breath, my everything. I see the bones – and guess what? – sometimes when i catch my reflection without warning I cringe too – but there’s always a thrill. there’s always this sweet satisfaction that i am unwell, I am so thin that i am dying. I have succeeded at something in this world. I dont like the way people look at me and I feel the burning up my spine when people stare, but then if they didnt stare ? I’m not starving enough, I need to starve MORE.
Yes – ever-present is the “need” to lose more weight, but for me, this need came from the constant fear that i would meet someone who is thinner than I. someone that would take away all my glory …. and make me nothing again. There is no Perfect, I don’t think I even seek that – I just so badly want that malnourished frame to save me from Mediocre. Hell.

thanks for blogging on this though – anorexia is , however poisonous and butchering to my life, also a large part of who i am and what my life has been thus far. It cannot be ignored and I can only hope that the great minds of this world continue to search for a way to heal me, or show me how to heal myself .

would love to know more about this new categorization of ED’s – much overdue. There’s nothing worse than telling some young girl she is too fat to be anorexic, or too controlled to be bulimic – she’ll die before they give her the right diag-nonsense.

Thanks for your comment. It is valuable to hear from someone who has this disorder. Yours is another case of those times that the person does not fit neatly in to the box we were taught in our training. Sometimes the need for control, to be the best at anorexia outweighs even the realization you have gotten too thin.

My son is going to be 7 and my mother stumbled upon this article in Ladies Home Journal October 2012 where I got a first glimpse of Avoidant/Restrictive Food Intake Disorder and Finicky Eating in Adults. My son ate fruits and vegetable in baby food content, since he stopped baby food he has never eating a fruit or vegetable. I tried to get him to eat a tiny piece of fresh strawberry with sugar on it and it literally made him gag. I even offered to go to the Dollar Store if he just TRIED it. He did try and threw it up into the trash. There are only a few thing of health he eats which are a bit of dairy. Yogurt (Vanilla only, no texture) and squares of yellow (fake) cheese. Otherwise he eats chips, pop corn, pizza (with sauce – only the microwaveable frozen ones) He eats peanut butter orange crackers. Chocolate covered granola bars. He does not eat yogurt that has a any texture, milk, any form of fruit. Here is an example of his ‘what I’ve come to figure is a texture issue’ he had a cheese quesadilla from Taco Bell and they accidently dropped a piece of iceberg lettuce on there. Once it hit his mouth he spit it out and refused to eat there for over a month. He will drink an orange slushy (until he hits pulp). When I make spaghetti for the family, he eats two pieces of garlic bread and not even a plain noodle. I speak with his ped and she says he is on the growth charts as normal and to just keep offering. I can go on and on, I just wanted to throw in some comments of how frustrating it is to see this going on where in comparison to his sister 9 eats broccoli and TRIES anything. Ironically she is my one who is on the mildly heavy side. I think she is going to stretch very soon. Two more comments. He was at a friend’s house and they text me, “what does he eat, we don’t have mac and cheese?” I had to pick him up. I got a call from his teacher, he forgot his lunch box at home which contains crackers, apple juice, fruit snacks (sugary things) and a rice crispy treat, she said Elliot is crying because he has to go through the lunch line and they are going to make him eat stuff. I had to speak with him on the phone and said just because it is on your tray you do not have to eat it. See if you can find something like a piece of bread on a sandwich that has no mayo and maybe a bag of chips. Just throw away what you don’t eat, you won’t get into trouble. It is a continuous battle, and I’m finally understanding that this probably has very little to do with how he was raised. On a side note he has a mild case of Turrets. Ticks, etc. Not sure if that has anything to do with it. He eats a gummy vitamin and that is my only thing that helps me not feel like a bad mom. ;( He did tell me when he turns 18 he will try another strawberry, this was just said about 2 weeks ago. ;)

Thanks for sharing that great description of the issues your son is having and you are having trying to be supportive of your son. My suggestion to you, for what is worth, is to seek out someone who specializes in Feeding disorders as nothing we were taught about eating disorders has any relationship to the issues you are describing. Hopefully someone can find a way to help you and your son.

As of today yes they are two separate things. The feeding disorders are included in the DSM-4 under Disorders First diagnosed in Infancy, Childhood and Adolescence. These disorders are treated by child specialists. In May of next year when the new DSM-5 is released feeding disorders will move to the chapter on Eating Disorders in recognition of the possibility of adults also having these disorders. I expect most therapists, even those who have experience with eating disorders like anorexia or bulimia will have little or no idea how they might be able to help with a feeding disorder. My feeling is that, yes, these two problems are two separate and very different things even if they end up in the same chapter of the new DSM-5.

*Just shows how LITTLE is known about us, adults.* * * *I’m beginning to believe (if caught early enough), a child with ARFID can be helped by Occupational Therapists, using a variety of techniques, such as “brushing” to stimulate and encourage the tactile oral senses.* * * *Time will tell!* * * *Marla :-)* *www.frenchfrylady.com* * * On Tue, Mar 19, 2013 at 11:16 AM, counselorssoapbox wrote:

> ** > davidmillerlmft commented: “As of today yes they are two separate > things. The feeding disorders are included in the DSM-4 under Disorders > First diagnosed in Infancy, Childhood and Adolescence. These disorders are > treated by child specialists. In May of next year when the new DSM-5 i” >

Jo Davis: Please don’t feel like a bad mother. This is not your fault. I am a 32 year old woman with ARFID. The woman you read about in Ladies Home Journal is a friend of mine named Heather. Heather and I met through a support group called Picky Eating Adutls (www.pickyeatingadults.com). I would recommend you check that out. It isn’t just for adults, Heather and I, like Elliot, started out as a picky eating child displaying the same behaviors that he does. I also do a podcast on this matter and you can check it out a peainapodcast.com. I haven’t updated it in a while because I started law school back in the fall and that keeps me busy but the information is still good. I am not a medical professional, just a girl trying to reach out to other picky eaters who report these kinds of problems.
I had two older brothers who ate anything. My parents could not have done anything different for me to have me turn out any differently. Love Elliot and know that he would change this if he could. It is a texture problem but researchers are just beginning to scratch the surface of this problem so there is a lot to learn. Check out the websites and if you truly want to seek support on this issue, you can email me at peainapodcast@gmail.com or I can provide my phone number if that works best for you. I advocate for awareness and I have had other mothers ask to talk to me on the phone before. You’re in good company :)

Quite likely people with ARFID experience sensitivity to some foods. Does this make ARFID a MENTAL Disorder? Will talking about it, seeing a therapist or changing your thinking and behavior cure this disorder? This post is part of a series on revisions to the Diagnostic and Statistical Manual of MENTAL disorders. (Emphasis added.)
Sensitivity is a term that lacks precision in mental health. Is the teen who throws things at the teacher, breaks windows and gets sent to juvenile hall, the one we are diagnosing with Disruptive Behavior Disorder, suffering from a sensitivity to teachers?
Sensitivity like allergy has a different meaning when applied to mental disorders than when applied to medical conditions.
I am inclined to think that is was an error to lump feeding disorders in with eating disorders. Anorexia is about thinking not sensitivity to food.
This movement in to the DSM has resulted in all of you with ARFID no longer having a medical condition but you are all now mentally ill. Could this alter your insurance coverage for the condition? Do you want to see a counselor for 45 minutes each week to treat your condition?
I did not decide this. The APA did.
As a result of these changes to the definitions of mental illness there is now debate about which DSM will be used for treating and paying for treatment of mental illness.
ARFID is a good example of why the DSM-5 may work for researchers in labs but those who are seeing clients for therapy may continue to use the DSM-4 and the ICD-9.
My hope is that those of you who have ARFID will find help. My thinking is this help needs to be from an MD not a psychotherapist.
Thanks for your comment.

I, too, believe my son may have ARFID. He is 9 and has been diagnosed with Autism PPD-NOS, and is high functioning. As a toddler, he ate most of the baby cereals and toddler foods but latched onto yogurt around 1. By the age of 2, he began refusing more and more foods to the point where we added pediasure to his diet to supplement. His diet since then has consisted of vanilla yoplait yogurt, vanilla pediasure, and toast (sporadically). He will only drink very small amounts of water and no other beverage besides pediasure.

We have been working with a therapist for 3 yrs now and the focus is primarily on trying new foods. Since therapy began, the most important improvements have been : 1. his anxiety and fear of new foods has greatly diminished – we encourage him to select the foods he will try and he enjoys smelling the fruits and veg to decide. 2.his overall oral sensitivity has declined – we are able to better care for his teeth which has always been extremely difficult. 3. He is responding more normally to hunger stimulus – certain cooking smells or ‘food games’ make him hungry. 4. He is nibbling several new foods and actually will tell people he likes them! Unfortunately, nibbles are truly tiny nibbles.

Progress has been slow and I don’t know if at this rate he will ever be able to have normal lunches at school or even normal dinner dates. I wish I knew more of how to help him but I do believe reducing the anxiety around food is one of the keys to his success. We were lucky that we could see, even as a young boy, how desperately he WANTED to eat for us but threw up over and over. Still today, therapy sessions evoke multiple gag reflexes and sometimes a full throw up.

I don’t see his food issues related at all to his want or need to remain thin. I see it the other way around, his inability to eat a full and balanced diet contributes to his slim build. Nutritionally, he is sound, thanks to pediasure, but I do wish is didn’t contain so much sugar.

Great comment and thanks so much for sharing your experience. It is a good thing that you found a therapist that has been able to work with him and help him. Your sion is lucky to have such a determined mother. This is not a disorder that we ever heard about in grad school and most therapists would have no clue on where to start on helping a child with this issue. Thanks for pointing out that this is not a desire to control weight but an inability to eat. Lets hope that there is more research and awareness for this condition.